Exam 3 Nursing Review: Oxygenation, Wound Care, Perioperative, Pain, and Nursing Process

A set of practice questions covering oxygen delivery, cardiac function, skin integrity, perioperative safety, pain management, and the nursing process.}```

What are the standard flow rate and FiO2 delivery for a nasal cannula?

The nasal cannula delivers $1-6\,L/min$ which provides an FiO2 of $24\%-44\%$.

At what flow rate should oxygen via nasal cannula be humidified to prevent drying of the nasal mucosa?

Oxygen should be humidified if the flow rate is $\ge 4\,L/min$ and used long term.

Which oxygen delivery device is used in emergency situations to provide high concentrations of oxygen ($60\%-90\%$ FiO2) quickly?

A nonrebreather mask using a flow rate of $10-15\,L/min$, ensuring the reservoir bag remains at least partially inflated.

Which oxygen mask provides the most precise concentration of FiO2?

The Venturi mask, which delivers between $24\%-60\%$ FiO2 depending on the specific flow rate set ($4-12\,L/min$).

What is the primary difference in pain relief between Angina and a Myocardial Infarction (MI)?

Angina is relieved by rest and nitroglycerin, whereas pain from a Myocardial Infarction is not relieved by rest, position change, or sublingual nitroglycerin.

What are the clinical manifestations of Right-sided Heart Failure?

Manifestations include weight gain, distended neck veins (JVD), hepatomegaly, splenomegaly, and dependent peripheral edema.

In the context of hypoxia, what is considered an early sign versus a late sign?

Restlessness and apprehension are early signs, while cyanosis (blue discoloration) is a late sign.

Why is carbon monoxide (CO) exposure considered dangerous for oxygenation?

CO binds to hemoglobin much more strongly than oxygen, creating a "functional anemia" where hemoglobin becomes unavailable for oxygen transport.

What is the "hypoxic drive" in COPD patients, and what are the implications for oxygen therapy?

COPD patients may rely on low PaO2 to stimulate breathing; providing too much oxygen (typically $>1-3\,L/min$) can eliminate this stimulus and lead to hypoventilation and respiratory arrest.

How frequently should a patient at risk for pressure injuries be repositioned?

Every $2$ hours, or every $90$ minutes if using specific support surfaces according to some newer guidelines.

What is the difference between granulation tissue, slough, and eschar in a wound bed?

Granulation is red, moist tissue indicating healing; slough is yellow or white nonviable tissue; and eschar is black or brown necrotic tissue.

What are the immediate nursing actions for an eviscerated wound?

Stay with the patient, call for help, and cover the exposed organs with sterile gauze soaked in sterile normal saline; do not attempt to reinsert organs.

What are the score ranges and risk levels for the Braden Scale?

The scale ranges from $6-23$. A score of $18$ is the common cutoff for risk; $\le 9$ indicates very high risk, while $15-18$ indicates mild risk.

During which perioperative phase should prophylactic antibiotics be administered?

Antibiotics should be given within $60$ minutes before the surgical incision and usually stopped within $24$ hours postoperatively.

What are the three core principles of The Joint Commission's Universal Protocol for surgery?

Preoperative verification, site marking with indelible ink, and the Time-out procedure involving the entire surgical team.

What is the standard frequency for performing "Turn, Cough, and Deep Breathe" (TCDB) exercises postoperatively?

TCDB should be performed every $2$ hours ($q2h$).

What common GI side effect of opioids does not diminish as the patient develops tolerance?

Constipation; patients do not develop tolerance to this side effect and it must be proactively treated.

What is the primary safety rule regarding the use of Patient-Controlled Analgesia (PCA)?

Only the patient is allowed to press the PCA button; use of "PCA by proxy" by family or visitors is strictly prohibited for safety.

What are the three parts of a nursing diagnosis in the PES format?

1. Problem (diagnostic label), 2. Etiology ("related to"), and 3. Signs/Symptoms ("as evidenced by").

What is the difference between a nursing goal and a nursing outcome?

A goal is a broad statement of desired change, while an outcome is a specific, measurable, and time-limited criterion used to evaluate if the goal was met.